DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved: OMB No. 0990-0269. See OMB Statement on Reverse. OFFICE FOR CIVIL RIGHTS (OCR) HEALTH INFORMATION PRIVACY COMPLAINT YOUR FIRST NAME HOME PHONE (Please include area code) STREET ADDRESS STATE ZIP YOUR LAST NAME WORK PHONE (Please include area code) CITY E-MAIL ADDRESS (If available) Are you filing this complaint for someone else? Yes No If Yes, whose health information privacy rights do you believe were violated? FIRST NAME LAST NAME PERSON / AGENCY / ORGANIZATION Who (or what agency or organization, e.g., provider, health plan) do you believe violated your (or someone else's) health information privacy rights or committed another violation of the Privacy Rule? STREET ADDRESS STATE ZIP CITY PHONE (Please include area code) When do you believe that the violation of health information privacy rights occurred? LIST DATE(S) Describe briefly what happened. How and why do you believe your (or someone else's) health information privacy rights were violated, or the privacy rule otherwise was violated? Please be as specific as possible. (Attach additional pages as needed) Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature. SIGNATURE DATE (mm/dd/yyyy) Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your complaint. We collect this information under authority of the Privacy Rule issued pursuant to the Health Insurance Port ability and Accountability Act of 1996. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible health information privacy violations, for internal systems operations, or for routine uses, which include disclosure of information outside the Department for purposes associated with health information privacy compliance and as permitted by law. It is illegal for a covered entity to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under the Privacy Rule. You are not required to use this form. You also may write a letter or submit a complaint electronically with the same information. To submit an electronic complaint, go to OCR's Web site at: www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. To submit a complaint using alternative methods, see reverse page (page 2 of the complaint form). HHS-700 (7/09) (FRONT) PSC Graphics (301) 443-1090 EF American LegalNet, Inc. www.FormsWorkFlow.com The remaining information on this form is optional. Failure to answer these voluntary questions will not affect OCR's decision to process your complaint. Do you need special accommodations for OCR to communicate with you about this complaint? (Check all that apply) Braille Large Print Cassette tape Computer diskette Electronic mail Sign language interpreter (specify language): Foreign language interpreter (specify language): Other: TDD If we cannot reach you directly, is there someone we can contact to help us reach you? FIRST NAME HOME PHONE (Please include area code) STREET ADDRESS STATE ZIP LAST NAME WORK PHONE (Please include area code) CITY E-MAIL ADDRESS (If available) Have you filed your complaint anywhere else? If so, please provide the following. (Attach additional pages as needed) PERSON / AGENCY / ORGANIZATION / COURT NAME(S) DATE(S) FILED CASE NUMBER(S) (If known) To help us better serve the public, please provide the following information for the person you believe had their health information privacy rights violated (you or the person on whose behalf you are filing). ETHNICITY (select one) Hispanic or Latino Not Hispanic or Latino RACE (select one or more) American Indian or Alaska Native Black or African American Asian White Native Hawaiian or Other Pacific Islander Other (specify): PRIMARY LANGUAGE SPOKEN (if other then English) How did you learn about the Office for Civil Rights? HHS Website/Internet Search Fed/State/Local Gov Family/Friend/Associate Religious/Community Org Lawyer/Legal Org Other (specify): Phone Directory Employer Healthcare Provider/Health Plan Conference/OCR Brochure To submit a complaint, please type or print, sign, and return completed complaint form package (including consent form) to the OCR Headquarters address below. U.S. Department of Health and Human Services Office for Civil Rights Centralized Case Management Operations 200 Independence Ave., S.W. Suite 515F, HHH Building Washington, D.C. 20201 Customer Response Center: (800) 368-1019 Fax: (202) 619-3818 TDD: (800) 537-7697 Email: ocrmail@hhs.gov Burden Statement Public reporting burden for the collection of information on this complaint form is estimated to average 45 minutes per response, including the time for reviewing instructions, gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of Information Resources Management, 200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201. Please do not mail this complaint form to this address. HHS-700 (7/09) (BACK) American LegalNet, Inc. www.FormsWorkFlow.com COMPLAINANT CONSENT FORM The Department of Health and Human Services' (HHS) Office for Civil Rights (OCR) has the authority to collect and receive material and information about you, including personnel and medical records, which are relevant to its investigation of your complaint. To investigate your complaint, OCR may need to reveal your identity or identifying information about you to persons at the entity or agency under investigation or to other persons, agencies, or entities. The Privacy Act of 1974 protects certain federal records that contain personally identifiable information about you and, with your consent, allows OCR to use your name or other personal infor